Dispensing of tamsulosin 400 microgram capsules (indicated for benign prostatic hyperplasia) has been temporarily switched to monthly from 1^st August, 2026. An upcoming supply issue affecting tamsulosin is anticipated from mid-September and this change is being made now to manage stock levels and ensure patients can continue to access this medicine. There is currently no date to resume stat dispensing, but resolution of the supply issue is expected by late September.

Long-acting propranolol 160 mg capsules (Cardinol LA), indicated for cardiovascular conditions, will be discontinued by the supplier from the end of July. An alternative brand, Propanolol Lupin, will be listed on the Pharmaceutical Schedule from 1^st August, 2026; the package labelling contains information in both English and French and it is not approved by Medsafe, so must be prescribed for supply under Section 29A of the Medicines Act 1981. Dispensing of long-acting propranolol will also temporarily switch to monthly from 1^st August, 2026, to enable the supply of the alternative brand to stabilise.

The Coversyl brand of perindopril is being updated (as reported in Bulletin 151). The original formulation of Coversyl (containing perindopril erbumine) is being discontinued by the supplier and replaced with a new formulation (containing perindopril arginine). Stock of the original 2 mg and 8 mg tablets is expected to be exhausted in September, and stock of the original 4 mg tablet will run out sometime in November. Medsafe considers both salts of perindopril interchangeable, however, they have different weights meaning direct substitution (and dosing) of one form to the other is not possible.

From 1^st September, patients who receive 2 mg and 8 mg strength perindopril tablets will need to be prescribed the equivalent strength of the new formulation (see Table 1). Patients receiving the 4 mg tablets should be prescribed the equivalent strength of the new formulation from October. In each case, a new prescription will be required.

Table 1. Perindopril (Coversyl) dose equivalence.

* Pharmac has not currently provided a specific date for transition of patients receiving 4 mg tablets. This may be updated on the medicine notice in due course.

Prescribers and pharmacists should advise patients of the changes to their medicine formulation and packaging, and why the dose of their tablets appears to be increased. Provide reassurance that the new tablets contain the same amount of the active component and will provide the same effect. Adverse effects are not anticipated with the change, however, patients should be advised to contact their prescriber if they notice any new symptoms.

Monthly dispensing of all strengths of perindopril tablets is in place to extend stock of the original Coversyl formulation while awaiting the new version (containing perindopril arginine). Stat dispensing will be reinstated from 1^st September.

A patient information sheet is available here.

A 2026 study of two patient cohorts published in Blood reported a significantly increased fracture risk one to six months after treatment with a single infusion of ferric carboxymaltose, compared to ferric derisomaltose. In the larger cohort of > 20,000 patients there was a more than doubling of fracture risk after treatment with ferric carboxymaltose (hazard ratio [HR] = 2.03, 95% confidence interval [CI] = 1.35 – 3.06).⁴ The fracture risk was the same in those with and without hypophosphataemia.⁴ Dr Ian Morison, Haematologist, comments that, while the study was not perfect: “The baseline five-year fracture risk of participants in the study was 5% and this increased after ferric carboxymaltose treatment to 13 – 14%; that is, 8 – 9% of people who receive an infusion with ferric carboxymaltose may have a fracture attributable to this treatment within the next five years.”

Therefore, any patient who receives a ferric carboxymaltose IV infusion is increasing their risk of fracture. The risk of hypophosphataemia and related complications is greater in patients who require repeated iron infusions.² However, other risk factors should also be considered; Medsafe provided a list in a 2024 Prescriber Update, including:

• Treatment with ferric carboxymaltose
• Recurrent or ongoing blood loss (e.g. abnormal uterine bleeding, hereditary haemorrhagic telangiectasia, gastrointestinal bleeding)
• Malabsorptive disorders (e.g. bariatric surgery, inflammatory bowel disease, coeliac disease)
• Normal renal function (decreased urinary phosphate excretion associated with kidney disease provides partial protection)²
• Severe iron deficiency
• Low body weight
• Low baseline serum phosphate
• High serum parathyroid hormone (PTH)

At present, the only alternatives to ferric carboxymaltose in the community are oral iron and ferric polymaltose IM injection. Given that the Special Authority criteria for ferric carboxymaltose specify that patients must have previously found oral iron treatment ineffective or intolerable, or require rapid correction of anaemia, oral iron is unlikely to be a suitable alternative in most cases. Ferric polymaltose is associated with a lower risk of hypophosphataemia, but is not favoured as IM injection is painful and can cause persistent discoloration of the skin and scarring.^{1, 5} Ferric derisomaltose (Monofer) is an alternative parenteral iron formulation with comparable efficacy that is associated with a significantly lower risk of hypophosphataemia than ferric carboxymaltose.³ It has been funded in the hospital setting since 1^st March, 2026 for patients who meet certain criteria, but is not funded for use in the community.

Prescribers should be aware of the risks associated with ferric carboxymaltose and routinely discuss these with patients prior to prescribing. The New Zealand Formulary recommends pre-treatment testing and ongoing monitoring of serum phosphate in patients with risk factors for hypophosphataemia.

The final word: watch this space as the evidence develops and treatment guidelines are updated. As Dr Ian Morison puts it: “It is no longer ethical to offer FCM [ferric carboxymaltose] infusion without a clear discussion of this risk.”

N.B. The bpac^nz article on IV iron treatment will be updated in due course, including revision of the ferric carboxymaltose Special Authority criteria that were last updated in November, 2024.

References

1. Medsafe. Reminder: Risk of hypophosphataemia with iron infusions. 2024. Available from: https://www.medsafe.govt.nz/profs/PUArticles/December2024/Reminder-risk-of-hypophosphataemia-with-iron-infusions.html (Accessed Jul, 2026).
2. Martens KL, Wolf M. Incidence, mechanism, and consequences of IV iron–induced hypophosphatemia. Hematology Am Soc Hematol Educ Program 2023;2023:636–9. doi:10.1182/hematology.2023000521.
3. Magagnoli J, Knopf K, Hrushesky WJ, et al. Ferric carboxymaltose (FCM)-associated hypophosphatemia (HPP): A systematic review. Am J Hematol 2025;100:840–6. doi:10.1002/ajh.27598.
4. Wagner SA, Panzer M, Pertler E, et al. Ferric carboxymaltose increases fracture risk in patients and reduces bone formation in mice with iron deficiency anemia. Blood 2026;148:15–30. doi:10.1182/blood.2025031806.
5. Aung T, Coleman J, Davidson PW, et al. Intravenous iron infusion and newer non-dextran formulations. NZMJ 2021;134:118–27.

• HPV-related oropharyngeal cancer is increasing. Smoking and HPV infection are established risk factors, however, many patients are younger and have no history of smoking (or heavy alcohol use), making early identification and diagnosis challenging.
• HPV vaccination prevents cancer. Approximately one-quarter of head and neck cancers are related to HPV. Increasing vaccine uptake remains one of the most effective strategies to reduce future HPV-related head and neck cancers, supporting Aotearoa New Zealand’s goal of 90% of females aged 15 years fully vaccinated by 2030.
• Equity requires proactive care. Māori continue to experience poorer outcomes, highlighting the importance of timely referral, active follow-up of missed appointments and early involvement of Māori Cancer Navigators (where appropriate and available).
• A persistent neck lump in an adult is cancer until proven otherwise. Any neck lump persisting for more than three weeks, particularly if it is firm, immobile, enlarging or non-tender, warrants urgent assessment. Transient neck lumps lasting fewer than three weeks are often related to infection.
• Associated symptoms may include new or unexplained hoarseness, dysphagia, throat or ear pain and oral ulceration. Weight loss, fatigue and night sweats may be associated with lymphoproliferative disorders such as lymphoma.
• Urgent referral should not wait for investigations. Immediately submit a referral marked “high suspicion of cancer” (or a Faster Cancer Treatment referral depending on your region and referral system) to ENT if cancer is suspected. Blood tests, ultrasound and fine-needle aspiration (preferably ultrasound-guided) can be arranged in parallel.

The role of primary care clinicians in the management of patients with thyroid eye disease includes education, general management of their thyroid dysfunction, early identification of potential thyroid eye disease and appropriate referral.

Background

• Thyroid eye disease is an autoimmune condition that is most commonly associated with Graves’ disease, affecting between 25 – 50% of this population group. It generally develops within two years of being diagnosed with hyperthyroidism.
  • Approximately 10% of people with thyroid eye disease will be euthyroid or hypothyroid
• The incidence of thyroid eye disease is higher in females, although severe disease is more likely in males
• The pathophysiology involves cross-reactivity between thyrotropin receptor autoantibodies (TRAb) and thyroid-stimulating hormone receptors (TSHR) on orbital fibroblasts, resulting in production of inflammatory cytokines, local swelling and the activation and recruitment of immune cells in orbital connective tissues and fat

Prevention and early detection in primary care

• Discuss the risk of developing thyroid eye disease in all patients diagnosed with Graves’ disease. This should include information about early warning signs for thyroid eye disease, what to do if symptoms develop, the importance of lifestyle changes (i.e. smoking cessation, if relevant) and medicines adherence to achieve and maintain euthyroid status and limit disease progression
• Identify and treat hypercholesterolaemia (with a statin) as elevated cholesterol is associated with thyroid eye disease
• Earlier identification of mild thyroid eye disease increases the likelihood of good visual and quality-of-life outcomes
• Restoration and maintenance of euthyroid status to treat Graves’ disease may prevent progression of thyroid eye disease
  • Thyroid function measurements do not always match disease activity or severity, therefore regular screening for symptoms and signs is critical
• Assessment for thyroid eye disease must occur as part of ongoing thyroid disease monitoring, and focus on key ocular symptoms:
  • Swelling of upper eyelids and new lower eyelid “bags” or festoons
  • Changes in eye appearance, e.g. redness, appearing more “wide open”
  • Spontaneous pressure-like pain behind the eye or pain increasing with eye movement
  • Vision changes, e.g. blurred or double vision

Symptoms

• There are two phases of thyroid eye disease:
  • Initial phase: inflammatory changes (may resemble dry eye disease or seasonal allergic conjunctivitis)
    • Watery and gritty eyes, photosensitivity, redness, eye pain, blurred vision and/or oedematous eyelids, particularly in the morning
    • Increased orbital tissue volume causes proptosis and eyelid retraction; double vision and reduced ocular motility suggest extraocular muscle involvement
  • Inactive phase: some symptomatic improvement expected
    • Proptosis, eyelid retraction and strabismus (crossed eyes) may persist, potentially requiring surgical correction
• The Clinical Activity Score (CAS) is a 7-question assessment tool for the symptoms and signs relating to thyroid eye disease that can be used to establish active disease (CAS score of ≥ 3). A further three questions relating to functional impairment can be added during follow-up at one to three months.
• Severity is determined by functional and cosmetic consequences:
  • Mild: most patients only experience minor symptoms, e.g. lid reaction < 2 mm, mild soft tissue involvement, proptosis < 3 mm above normal for ethnicity and sex, no or intermittent diplopia. Corneal exposure can be managed with lubricant eye drops (or an ointment overnight) and there is limited impact on daily life.
  • Moderate-to-severe: 20 – 30% of patients experience lid reaction ≥ 2 mm, soft tissue involvement, proptosis ≥ 3 mm above normal for ethnicity and sex, diplopia, with a moderate impact on daily life. Symptoms may require immunosuppressive or surgical treatment.
  • Sight-threatening: 3 – 5% patients develop dysthyroid optic neuropathy or corneal breakdown (due to exposure). Risk factors for progression to dysthyroid optic neuropathy include smoking, older age at diagnosis, diabetes, obstructive sleep apnoea, higher CAS and elevated TRAb (≥ 5.0 IU/L). Patients with sight-threatening disease typically present with one or more of: reduced visual acuity or colour vision, visual field deficits, optic disc swelling or relative afferent pupillary defect.

Referral

• In New Zealand, all patients with confirmed hyperthyroidism and symptoms suggestive of thyroid eye disease require thyroid assessment with an endocrinologist to manage their thyroid dysfunction and assess for thyroid eye disease (see local HealthPathways). Further ophthalmology review is generally arranged in secondary care but may be required if patient’s symptoms progress before a thyroid assessment can occur.
  • This may involve a baseline MRI or CT scan to establish the degree of extraocular muscle enlargement, inflammation and orbital fat expansion
  • Some patients with ocular symptoms may present to an optometrist, who can refer them for ophthalmology review
• Patients with red flag symptoms indicating severe or rapidly progressing thyroid eye disease (e.g. reduced visual acuity or altered colour vision, new-onset diplopia, rapidly progressive proptosis or globe subluxation) require acute ophthalmology assessment and ophthalmology advice (same day)

Management in primary care

• Initial interventions recommended for all patients with thyroid eye disease (and may be sufficient for patients with mild symptoms) include:
  • Lubricating eye drops/ointment, e.g. dextran + hypromellose (funded), retinol palmitate ointment (funded), hyaluronate sodium (funded with Special Authority)
  • Symptom specific strategies, e.g. dark sunglasses for photophobia, head elevation while sleeping to alleviate oedema
  • Vitamin D and selenium (during active disease) supplementation
• The active phase of moderate-to-severe thyroid eye disease typically requires ophthalmology management including medicines (e.g. intravenous corticosteroids, immunosuppressants, biologics) or orbital radiotherapy
  • Surgical interventions, such as orbital decompression and eyelid recession repair, are a multi-step process and typically considered once the patient’s symptoms have stabilised
• People with thyroid eye disease who experience more than transient diplopia in the primary position (straight-ahead alignment) should not drive until their condition has been assessed and satisfactorily treated (for further information, see Medical aspects of fitness to drive – A guide for health practitioners)
  • There may be exceptions for patients who experience diplopia when only looking in a certain direction
  • Diplopia generally excludes people from commercial class licenses and endorsement, unless there are exceptional circumstances and the application is supported by an optometrist or ophthalmologist